CurrentFlorida BluePolicy N/A

CT scan reimbursement allowed amounts (code/modifier pricing list)

A payer pricing table listing procedure codes, modifiers, and allowed amounts for CT scan services. Affects billing/coding and reimbursement for providers submitting CT-related CPT/HCPCS codes to Florida Blue.

Policy Summary

PayerFlorida Blue

PolicyCT scan reimbursement allowed amounts (code/modifier pricing list)

Policy CodePolicy N/A

Change TypeNo material changes / informational update

Effective DateN/A

Next Review DateN/A

Key ActionUse the listed allowed amounts and modifier-specific pricing when submitting claims for CT-related CPT/HCPCS codes to Florida Blue.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

60+procedure codes

$275.94sample allowed amounts

02,26,TCmodifiers present

multipleTC/26/02 splits

Coverage Criteria / Pricing Notes

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Reimbursement entries only

This extract provides allowed amounts per procedure code and modifier; no clinical coverage criteria are present in the provided text.

No clinical coverage or medical necessity criteria are stated in this excerpt; content consists of reimbursement allowed amounts listed by procedure code and modifier (examples: 0633T modifier 02 = S275.94; 70450 modifier 02 = S151.41; 70450 modifier 26 = S56.72).

Fee mapping entries (partial)

Pricing/mapping lines (partial extract).

This block contains code-to-price mapping lines and component indicators (e.g., 74175 mapped entries with TC/26/02 variants and S-prefixed dollar values; G0279 mapped to multiple T-codes with TC=02 and S-values). No medical necessity rules are provided.

Mapping-only (no criteria)

No coverage criteria stated; the content is mapping data.

Lines map IDTC GENERAL DIAGNOSTIC entries to CPT codes (examples: 70160 mapped to 70160/70170/70190 etc.) with component indicators (02, 26, TC) and S-prefixed numeric values; no clinical coverage criteria present in this excerpt.

No coverage rules in excerpt

No explicit coverage criteria are stated in this excerpt; content is mapping/pricing data for billing.

Fee schedule mapping rows showing CPT examples (e.g., 72170 series) with component flags (02/26/TC) and associated S-values. This excerpt contains pricing/mapping data only and does not define coverage or medical necessity rules.

Pricing/Coding mappings (partial)

No explicit coverage criteria or clinical limitations are present in this excerpt; it provides pricing/mapping information only.

CPT-to-value mapping lines (examples: 73615 mapped across ranges 73650–74019) with charge type indicators (02, 26, TC) and S-prefixed values. No clinical eligibility or medical necessity criteria are included.

Pricing table only

No clinical coverage criteria provided in this excerpt.

IDTC GENERAL DIAGNOSTIC mapping entries (e.g., 75630 mapped to 75716/75726/75731 etc.) include component indicators and monetary S-values; content functions as pricing entries only, not coverage rules.

Reimbursement/value crosswalk entries

This excerpt functions as a reimbursement/pricing crosswalk rather than narrative coverage criteria.

Contiguous CPT/HCPCS ranges (examples: 76511–76516, 76775–76802) are mapped to internal entries with component indicators (02/26/TC) and S-prefixed dollar values; no utilization or medical necessity conditions are specified.

Mapping table (no coverage rules)

No explicit coverage criteria in these chunks; content is code-to-value/component mappings.

Ultrasound and related CPT ranges (e.g., 76885–76946) are listed with 02/26/TC component splits and numeric S-values; this is mapping/pricing information without coverage rules.

Fee schedule fragment — no coverage criteria

This fragment provides fee schedule price entries and billing component indicators; it does not state coverage policy or clinical criteria.

Sample entries linking medicine/ECG codes (e.g., 95803 mapped to 93005–93024 variants) show payment indicators and S-values across 02/26/TC splits. No medical necessity guidance is present.

Pricing entries (partial)

This excerpt provides reimbursement price points for listed codes; it does not contain explicit coverage criteria or medical necessity rules in this window.

Respiratory/neurology/other medicine-related CPT mappings (examples: 94680, 95885, 95926 series) include component indicators and S-prefixed price values; entries are pricing mappings only.

Fee schedule entries (partial)

This segment provides pricing values and component indicators for listed service codes; it does not contain utilization or medical necessity criteria.

MRI/IMRA mapping lines (examples: 0609T, 0611T, 0648T, 70336) show allowed amounts with 02/26/TC variants and S-prefixed numbers; no coverage conditions are given.

Fee schedule mappings (informational)

This excerpt functions as a fee schedule mapping codes and billing components to dollar amounts; it does not state clinical coverage criteria.

MRI and Nuclear Medicine fee schedule lines (e.g., 73220–73720, 77084 mappings) present component pricing (02/26/TC) and S-values; content is pricing information, not medical necessity guidance.

Pricing table (informational)

This excerpt lists billing lines and associated prices; no explicit coverage criteria or medical necessity rules are provided in these chunks.

Nuclear Medicine code ranges (examples: 78104–78195, 78300–78445) include component indicators and monetary S-values across 02/26/TC splits; entries are reimbursement mappings only.

Mapping / Pricing (informational)

This section provides mapping and pricing information; it does not state coverage policy or clinical criteria in the provided excerpt.

IDTC Nuclear Medicine and PET Scan rows map broad CPT ranges (e.g., 79101->78433/78459/78491/78492 etc.) to allowed amounts (examples: S2,880.10 for 79101->78433 (02)) and component indicators; no clinical eligibility requirements are included.

Pricing table — no coverage rules in excerpt

Pricing/mapping entries (no explicit coverage criteria provided in this excerpt).

Additional IDTC rows (PET SCAN, SPECIALIZED DX SERVICE, SURGICAL CODES) show code mappings with 02/26/TC splits and S-prefixed dollar amounts (examples include S1,686.80, S1,804.14, S610.16); these are billing/pricing entries only and do not specify medical necessity rules.

Procedure Codes, Modifiers, and Mapped Amounts

Covered CT Procedure Codes (with modifiers)CPTCovered

0633T	IDTC CT SCAN
70450	CT scan, head/brain (example entry)

Diagnostic Imaging Code Mappings (partial)mixed

74175	CT scan code present in mappings
77011-77078	Mammography/digital mammogram series present
G0279	Digital diagnostic mammography G-code present
0930T-0947T (multiple T-codes)	General diagnostic temporary codes mapped to CPTs

Referenced CPT Codes (partial)CPT

70160-72255

Range of CPT codes referenced in mapping lines within these chunks

CPT Mappings PresentCPT

72170	CPT code mapping shown multiple times with different component flags and S-values
73040	CPT code mapping with TC/02/26 variations and S-values
73615	CPT code mapping with TC/02/26 variations and S-values

CPT to Payment Mappings (partial)CPT

73615-74360 (examples across excerpt)	Diagnostic radiology CPT codes mapped to payment values and charge types (02, 26, TC) as shown in lines
74420-75743 (examples across excerpt)	Additional diagnostic CPT code ranges with mapped payment values and charge types

IDTC Diagnostic Code Mappings (excerpt)mixed

75630 = 75716	Example mapping line showing code range and mapped internal code/price entry
75887 = 75894	Example mapping with a large dollar amount S1,338.42 shown for TC/02

Ultrasound / CPT Code RangesCPT

76511-76975	Multiple ultrasound/diagnostic CPT codes and ranges referenced
76775-76883	Obstetrical/abdominal ultrasound CPT codes with associated component indicators and numeric values
76885-76975	Additional ultrasound CPT codes with values

Observed Code Mappings and Cross-Referencesmixed

76981	Listed with multiple linked CPT/HCPCS codes and component splits
77077	Mapped to many other codes with component splits and values
95803	Mapped to various codes including diagnostic and mammography codes

Sample Codes from FragmentCPT

93005	Procedure code listed with payment indicators/amounts
93307	Procedure code listed with payment indicators/amounts
93897	Procedure code listed with payment indicators/amounts

Partial Code Price Listingsmixed

94680	Respiratory therapy/related code appears mapped to multiple target codes/prices
95700-95724 (examples)	Series of codes with S-amounts listed
95926-96013 (examples)	Neurology/EEG/nerve conduction series with S-amounts

Examples of CPT/HCPCS Codes in SegmentCPTCovered

0609T	Listed with a pricing value in this segment
0611T	Listed with a pricing value in this segment
0648T	Multiple entries with TC/26 variants and pricing
70336	MRI code with multiple component prices

MRI Codes in ExcerptCPT

73220	MRI code shown in fee schedule with multiple component prices
73718	MRI code shown in fee schedule with multiple component prices
73719	MRI code shown in fee schedule

Other Radiology / Nuclear Medicine CodesCPT

74712	Interventional/fluoroscopic or radiology code with component pricing
77084	Nuclear medicine / related code appearing in mappings
78104	Nuclear medicine code listed with multiple mapped values

Nuclear Medicine CPT/HCPCS Lines (partial)mixed

78104	IDTC Nuclear Medicine — multiple entries with modifiers and prices
78300	IDTC Nuclear Medicine — multiple entries with modifiers and prices
78431	IDTC Nuclear Medicine — price values listed

IDTC Nuclear Medicine and PET Scan Code Listmixed

78453-78499,78579-79005,79101-79999	Range of Nuclear Medicine and PET related CPT/HCPCS codes referenced in mappings and pricing rows in this section
TC / 02 / 26	Technical component (TC), global (02), and professional component (26) indicators noted alongside codes

Sample CPT / IDTC Codes PresentCPT

78433	IDTC PET SCAN (example entry)
78814	IDTC SPECIALIZED DX SERVICE (example entry)
78708	IDTC SURGICAL CODES (example entry)

Example allowed amount

Example allowed amount$275.94 for procedure code 0633T with modifier 02

Same allowed amount repeated$275.94 also shown for 0634T, 0635T, 0636T, 0638T with modifier 02

Other sample allowed amounts70450 (02) = $151.41; 70450 (26) = $56.72; 70450 (TC) = $94.69

Mapped dollar values

S‑prefixed mapped valuesMonetary values in the table are shown with an 'S' prefix (e.g., S83.49, S279.60, S191.95)

Mapped high-value examplesS1,073.46 (77011 mapping), S1,338.42 (75887 -> 75894 shown elsewhere)

Mapped component variantsValues differ by component/modifier (02, 26, TC) for the same code mappings

Charge type indicators

Charge type indicators present'02', '26', and 'TC' appear throughout the mapping table to denote pricing components

Examples in tableRows show TC = 02/26/TC and 02 = 26/TC for multiple CPT ranges

Used with S-valuesEach charge type row is paired with an S-prefixed dollar amount specific to that component

Highest shown single-dollar mapping

Highest single-dollar mapping shownS1,338.42 appears for mapping 75887 = 75894 (26 = 02) in the excerpt

Other large S-valuesS2,951.79 and S2,870.41 appear in nuclear medicine rows (78431, 78432)

ContextHigh S-values are shown alongside component indicators (02/26/TC) in fee mappings

Not applicable

Not applicableNo threshold or utilization limit specified in this fragment

Table natureContent is mapping/price entries only; no coverage thresholds included

Explicit dollar values present

Explicit dollar amounts presentSeveral entries show numeric dollar amounts (examples: S421.53, S314.01, 544.45) though presented as S-prefixed values

No coverage thresholdsThe excerpt lists prices but does not state explicit coverage/authorization thresholds

Examples across sectionsValues shown for CT, ultrasound and other diagnostic code mappings throughout the table

Payment indicator types present

Payment indicator types presentModifiers/payment indicators documented include 02, 26, and TC

Role of indicatorsUsed to denote professional (26), technical (TC) and other/global (02) payment components

Applied across code rangesIndicators appear for CPT/HCPCS entries in CT, MRI and Nuclear Medicine sections

Utilization thresholds

No utilization thresholds presentThe excerpt contains price mappings only; no utilization or frequency limits are specified

ImplicationBilling/pricing reference rather than clinical/utilization policy in this fragment

Component pricing noted

Component pricing notedEntries include separate values for 02, 26 and TC where applicable (e.g., same CPT mapped to different S‑values by component)

ExamplesMRI and CT rows show distinct S-values for 02, 26, TC (see 70336, 70540, 70450 examples)

Provider billing impactSubmit the correct modifier/component to align with the corresponding allowed amount in the table

Not applicable

Not applicableNo additional applicable threshold or note in this excerpt

Example PET Scan price

Example PET Scan price (02)S2,880.10 shown for PET SCAN mapping 79101 -> 78433 with modifier 02

PET component variantsSame mapping shows 26 = S140.12 and TC = S2,767.19 for 79101 -> 78433

Other PET entriesAdditional PET/related mappings show S1,218.29 (78491, 02) and S1,108.19 (78491, TC)

Example S188.45 value magnitude

S188.45 value magnitude examplesRows labeled with S188.45 map to a wide range of dollar amounts — from zero (SO.00) to multi‑thousand values like S2,880.10

Range contextS188.45 appears as an index value used to derive component S-values that range from low double digits to thousands

Table implicationShows variation in derived allowed amounts depending on target CPT and component indicator

Billing Guidance and Provider Notes

Billing Rule

Fee schedule excerpt — code mappings

This section provides fee schedule excerpts mapping procedure codes to allowed amounts and component indicators (02 = professional component, 26 = technical component, TC = technical charge). Use these values for billing and allowed-amount reference. No prior authorization or coverage criteria are included in this excerpt — it is a pricing reference only.

Includes CT scan, digital mammography, general diagnostic, MRI, nuclear medicine, PET scan, medicine, and MRIMRA fee schedule lines.
Values shown use an 'S' prefix for allowed amounts (e.g., S275.94) and list component indicators (02, 26, TC) where applicable.
Provider should bill using the CPT/HCPCS code with the appropriate modifier/component and the corresponding allowed amount from this fee schedule excerpt.

Terminology and Table Indicators

Allowed Amount

Allowed Amount (term)Term appears as 'Allowed Amount' in table context to denote the payer's allowed price for a procedure

UsageUsed with procedure code and modifier rows (e.g., 'Allowed Amount = S275.94' for 0633T)

PresentationAmounts are shown with an 'S' prefix in the excerpt

Modifier

Modifier examplesModifiers shown in the table include 02, 26, and TC to indicate payment component or billing variant

Modifier effectDifferent modifiers for the same CPT produce different allowed amounts in the table

Where shownModifiers are listed alongside procedure code rows throughout CT, MRI and Nuclear Medicine sections

IDTC (internal mapping identifier)

IDTC identifier'IDTC' appears as an internal pricing/code mapping identifier throughout the document (e.g., 'IDTC GENERAL DIAGNOSTIC')

ContextIDTC rows map internal identifiers to CPT/HCPCS codes and S‑values

Component/modifier designations

Component/modifier designationsComponent indicators used in mappings include TC, 26 and 02 (technical/professional/global variants)

Repeated usageThese designations appear in mapping rows across diagnostic, MRI and nuclear medicine sections

Effect on allowed amountEach designation is paired with a distinct S‑value for the same procedure mapping

IDTC GENERAL DIAGNOSTIC mapping line

IDTC GENERAL DIAGNOSTIC mapping lineLines labeled 'IDTC GENERAL DIAGNOSTIC' show a source identifier, target CPT, a component/modifier and an associated S‑value (e.g., G0279 = 0598T; TC = 02; S32.52 = S25.70)

PatternThe format repeats across many CPT mappings in the excerpt

Component indicators

Component indicators (examples)Entries represent technical component (TC) and other billing components shown as 02 or 26 in mappings

Examples in excerpt72170 and 73615 rows show TC/26/02 variations with different S‑values

02, 26, TC indicate component of payment

Meaning of 02/26/TC02, 26 and TC are used to indicate pricing components (e.g., global/other, professional, technical) as applied in mappings

Applied across sectionsUsed consistently across CT, ultrasound, MRI and nuclear medicine rows

Charge type (02/26/TC)

Charge type codes presentCharge type codes appearing in rows include '02', '26', and 'TC' to indicate component/price type

Displayed with code mappingsThese codes are listed alongside CPT mappings and S‑values in the table

Component indicators found

Component indicators found in entriesEntries list TC (technical), 26 (professional) and 02 (global/other) paired with target CPT and S‑values

Example rows76511–76514 and 95803 rows show component indicators and corresponding S‑values

Component indicators

Component indicators summaryTC = technical component; 26 = professional component; 02 = global/other split used in the mapping table

Practical noteSelect the appropriate modifier to match the payer's allowed amount for that component

Payment indicator

Payment indicator usagePayment indicator codes (examples: '02', '26', 'TC') appear with procedure codes to denote billing component or payment responsibility

Consistent formattingEach payment indicator row includes an associated S‑value for that component

Modifier / price type

Modifier / price typeModifiers '02', '26', and 'TC' are used in the table to indicate pricing components and map to distinct S‑values

ExamplesMultiple CPT entries demonstrate 02/26/TC variants with different allowed amounts

TC and 26 designations

TC and 26 designationsTC (technical component) and 26 (professional component) are used to indicate split billing/pricing for services

MRI examplesMRI rows list TC and 26 with separate S‑values for the same CPT mappings (see 70336, 70540 entries)

Price component codes

Price component codes definedIn the table: TC = technical component; 26 = professional component; 02 = modifier or component code used in mappings

Usage noteThese codes appear consistently next to CPT/HCPCS to indicate which component the S‑value applies to

Modifiers indicating components

Modifiers indicating componentsModifiers TC, 02 and 26 are repeatedly used in nuclear medicine and PET rows to show technical/professional/global split

Large-value examplesNuclear medicine rows include S‑values in the thousands for TC/02 variants (e.g., 78431, 78432 rows)

Indicators shown in rows

Indicators shown in rowsRows represent Technical component (TC), global/02 and Professional component (26) alongside code mappings

Practical effectProviders should bill with the correct component/modifier to receive the corresponding allowed amount

Table shows component indicators

Table component summaryThe excerpt displays TC, 02 and 26 component indicators which correspond to technical, secondary/modifier segments, and professional/global splits used in pricing

Example PET rowsPET SCAN entries show distinct S‑values by component (02, 26, TC) for the same mapped CPTs